Equity and utilisation of primary, specialist and dental health services in Spain

[eng] Although public health expenditure in Spain still account for more than 70% of all health expenditures, the importance of private financing in health care has risen over the last decades. The continued growth of private health expenditures is considered to have adverse consequences for equity in the access and utilization of health care services. Regarding the increase of out-of-pocket payments for complementary to the public sector health care, the main concern is that the poor members of the society are likely to reduce (or even not use at all) their utilization of health products and services more than the better-off. This may result in violation of the principle of horizontal equity, according to which people with similar needs should be treated equally, irrespective of their income. With respect to expenditures on private health insurance premia and on other health services that are substitutes to the ones provided by the public sector, the most important consideration is that those expenditures may ensure access to health services of a different "quality". The topics studied in this thesis follow up on the general knowledge about inequity in health and health care delivery by trying to study more in depth bow some aspects of private health care financing affect equity in the context of the mainly public Spanish Health Care System. Especially, we address the following three issues: a) the potential inequalities in the pattern of utilization of health care services due to socio-economic factors and not to differences in health; b) the determinants of the demand for private health insurance; c) the inequalities in dental health and dental care utilization. At chapter two we try to shed light into the investigation of differential patterns of utilization of physician services by populations subgroups that is emerging in a number of studies. Using Spanish data coming from the 1997 National Health Survey, we try to explain the distinct role of the type of insurance on the choice between specialists and GPs and its intertwining with the choice between private and public providers. We estimate a two-stages probit to conclude that differences in the insurance access is the main determinant of both the choice of provider and the type of physician contacted, giving rise to very different patterns of consumption of generalists and specialists visits. People with only public insurance access goes 2.8 times to the generalist per one time that they visit a specialist; individuals with duplicate coverage have a ratio of GP/specialists visits equal to 1.4 (the combination being public GP and private specialist) and people with only private insurance access actually have an "inverted" pattern of visits: they contact specialists more often than GPs - that it is against cost control, common sense and basic epidemiological recommendations. Age, sex and health also have a distinct and interesting impact on these choices. Finally, equity concerns based on the implied assumption that specialist care is superior to generalist care are discussed. Given that the type of insurance access appeared to be the main determinant of the choice of health care provider, we present a more comprehensive analysis of the decision to purchase voluntary health insurance in chapter three. In Spain the statutory health coverage already fulfils the basic function of health insurance, which is to smooth the financial risks associated with uncertain future health care costs. Consequently, the purchase of VHI must be motivated by other factors like inflexibilities of the public sector, private rooms in hospitals, personalised care, and different attributes of "quality". Approximately, 11% of the population buys supplemental private health insurance in Spain. The theoretical model behind the analysis is that of risk averse individuals who maximise their expected utility. We model the purchase decision based on individual and household characteristics as well as public and private health sector supply variables using data from the panel of the Spanish Family Expenditures Survey and other sources. Our results show that the decision is actually significantly influenced by a wide range of those variables. The importance of price is discussed by analysing the impact of the tax reform introduced in 1999 by which the existing tax deduction on individually bought private insurance policies was removed and employer-paid policies were instead fiscally favoured, according to our results, with success. In chapter two we studied the utilization of health services included in the public health benefits package, but for which some people buy supplementary health coverage. In chapter four, we analyze inequalities in the utilization of health services altogether excluded from the public finance and provision, that is, dental services. We employ the concentration index approach, which although commonly used in the research of income-related inequality in health and health care, has but never been applied to analyze inequity in dental health and dental care utilization before. The data (as in the empirical analysis in chapter two) comes from the 1997 Spanish Health Survey. Our findings confirm the hypothesis of the existence of significant income-related inequity in the distribution of good dental health favouring the better­ off. Regarding the analysis of equity in the utilization of dental care, we find significant pro-rich inequity in the utilization of dental services. Finally, the results from the analysis of inequities in the utilization of specific types of dental care reveals that preventive care (like diagnostics and teeth cleanings), basic restorative care and aesthetic services are concentrated among the wealthier segments of the population, while oral surgery (tooth extractions)-the cheapest way of treating a damaged tooth besides being the only one provided by the public sector - is the only type of dental care with unequal distribution favouring the poor. The existence of inequities in dental health and dental services utilization is to be expected in a system where high treatment prices, usually paid out-of-pocket, constitute an important barrier to access care. Including dental services, or at least preventive dental care, in the package of publicly provided health services may be the right policy to adopt

Socioeconomic burden of mental disorders in Spain 2006-2017

Mental health is not only the lack of mental disorders but is considered a crucial resource for overall health and well-being (including employment and productivity). The current paper tries to shed some light on the evolution of mental well-being over a period of 15 years, including the years before, during and after the most recent economic downturn. We use data coming from the Spanish National Health Surveys of 2006/2007, 2011/2012 and 2016/2017. Mental health is proxied by two measures, doctor-diagnosed mental disorder and psychological distress (based on GHQ-12). To account for the causal relationship between the two mental health indicators, we estimate a bivariate probit model. We observe different patterns of the two mental health indicators over time. Psychological distress increased during recession years, due to major risk factors as unemployment and loss of socioeconomic status. Even though the need for mental healthcare increased during the recession, the fact that fewer people were diagnosed suggests that barriers to access to mental healthcare may be aggravated during the crisis

The relationship between overweight and education revisited: a test of the selection hypothesis based on adolescents’ educational aspirations

Objectives: This paper examines the selection mechanism underlying the association between overweight/obesity and educational aspirations of adolescents. Study design: This is a cross-sectional study based on a survey conducted in secondary schools in Spain in 2016. Methods: We estimate linear probability models to determine the association between adolescents’ body mass index (BMI) and their expectations to obtain a university degree, as well as their school choices representing the most usual path towards higher studies. To address the potential endogeneity of BMI, we use the instrumental variables (IV) method. Additionally, we account for potential unobserved heterogeneity by including school fixed-effects and a wide set of individual and family characteristics in our analysis. Results: Our results indicate that adolescents with a higher BMI have lower expectations to obtain a university degree and are less likely to enrol in high school with the intention to pursue higher education in the future. The estimated effect is quite sizable and statistically significant only for girls. We estimate that a five-unit increase in BMI (e.g., the change between healthy weight and overweight) reduces girls’ expectations to complete higher education by 19 percentage points and odds of enrolling in high school (vs. vocational training) by 21 percentage points. Conclusions: We provide empirical evidence supporting the selection hypothesis behind the relationship between BMI and adolescents’ educational aspirations. That is, unhealthy weight in adolescence is associated with poorer aspirations for further education. Lower educational aspirations during adolescence can lead to lower academic achievement, which in turn, may result in poorer health, labour market outcomes, and well-being during adulthood

The causal relationship between Individual's choice behavior and self-reported satisfaction : the case of residential mobility in the EU

One of the most persistent and lasting debates in economic research refers to whether the answers to subjective questions can be used to explain individuals' economic behavior. Using panel data for twelve EU countries, in the present study we analyze the causal relationship between self-reported housing satisfaction and residential mobility. Our results indicate that: i) households unsatisfied with their current housing situation are more likely to move; ii) housing satisfaction raises after a move, and; iii) housing satisfaction increases with the transition from being a renter to becoming a homeowner. Some interesting cross-country differences are observed. Our findings provide evidence in favor of use of subjective indicators of satisfaction with certain life domains in the analysis of individuals' economic conduct

Changes in the demand for private medical insurance following a shift in tax incentives

The 1998 Spanish reform of the Personal Income Tax eliminated the 15% deduction for private medical expenditures including payments on private health insurance (PHI) policies. To avoid an undesirable increase in the demand for publicly funded health care, tax incentives to buy PHI were not completely removed but basically shifted from individual to group employer-paid policies. In a unique fiscal experiment, at the same time that the tax relief for individually purchased policies was abolished, the government provided for tax allowances on policies taken out through employment. Using a bivariate probit model on data from National Health Surveys, we estimate the impact of said reform on the demand for PHI and the changes occurred within it. Our findings suggest that the total probability of buying PHI was not significantly affected. Indeed, the fall in the demand for individual policies (by 10% between 1997 and 2001) was offset by an increase in the demand for group employer-paid ones, so that the overall size of the market remained virtually unchanged. We also briefly discuss the welfare effects on the state budget, the industry and society at large

Aplicació de les metodologies “Aprenentatge basat en Equips” i “Aula invertida” per a la millora de l’aprenentatge en els Grups d’Intensificació de l’Estudi (GIE) de les assignatures de Teoria Econòmica

Projecte: 2014PID-UB/031La introducció de tècniques d'aprenentatge actiu a les aules implica un canvi en l'esquema de docència tradicional ja que és l'estudiant qui passa a exercir el paper protagonista en el procés d’aprenentatge, mentre que el professor queda relegat a un plànol secundari com a acompanyant o guia del mateix. Malgrat l’existència d’estudis que mostren l'eficàcia de la seva aplicació, cap estratègia s'havia centrat a avaluar la seva implementació en grups d'estudiants repetidors. Així, la metodologia proposada –basada en l’aplicació de l’aula invertida i l’aprenentatge basat en equips- pretenia omplir aquest buit i va ser implementada en alguns Grups d'Intensificació de l'Estudi (GIE) d’assignatures que imparteix la Secció de Teoria Econòmica a la Facultat d’Economia i Empresa. Després d’aplicar l’estratègia docent a diversos grups GIE es van analitzar els resultats fruit de la seva aplicació a un total de 610 estudiants distribuïts en 7 grups GIE de 4 assignatures, una del grau d'ADE i 3 del grau d'Economia durant els cursos acadèmics 2013/14 i 2014/15. L'anàlisi dels resultats va avalar la seva eficàcia i superioritat enfront de la metodologia tradicional. És especialment destacable: (1) l'augment en la taxa d'estudiants presentats a l'examen final i (2) el major rendiment acadèmic dels estudiants.Projecte d’Innovació Docent 2014PID_UB/03

Students' perception of team-based learning: Evidence in Economics

Today's new teaching and learning methodologies in higher education have moved the center from teacher to student and from teaching to learning. Since Team-Based Learning (TBL) is one of the most frequently used active learning methodologies that have emerged, the objective of this paper is to analyze and evaluate students' perception of this methodology. To that end, first we study the positive and negative aspects of TBL considered by students. Then, we define a synthetic indicator to evaluate the degree of satisfaction of students with this methodology and analyze it according to sociodemographic variables. Finally, we analyze whether there is any correlation between the degree of satisfaction of each student and their individual final grade in global terms. The analysis is performed using a database (which includes information of 657 students) created by merging two datasets: an online questionnaire answered by students, and academic and sociodemographic information of the students who participated in the questionnaire. The main results show that TBL is perceived as a positive methodology, with respect to improving teamwork abilities. Significant differences in several competences were found by age groups, between students with or without a paid job, and depending on the educational attainment of their parents. The students' perception of TBL regarding motivation and performance during the learning process gives information about the sociodemographic characteristics of the students who will show greater acceptance and appreciation of the introduction of TBL

Low-cost, easy-to-build noninvasive pressure support ventilator for under-resourced regions: open source hardware description, performance and feasibility testing

Aim: Current pricing of commercial mechanical ventilators in low-/middle-income countries (LMICs) markedly restricts their availability, and consequently a considerable number of patients with acute/chronic respiratory failure cannot be adequately treated. Our aim was to design and test an affordable and easy-to- build noninvasive bilevel pressure ventilator to allow a reduction in the serious shortage of ventilators in LMICs. Methods: The ventilator was built using off-the-shelf materials available via e-commerce and was based on a high-pressure blower, two pressure transducers and an Arduino Nano controller with a digital display (total retail cost <75 USD), with construction details provided open source for free replication. The ventilator was evaluated, and compared with a commercially available device (Lumis 150 ventilator; Resmed, San Diego, CA, USA): 1) in the bench setting using an actively breathing patient simulator mimicking a range of obstructive/restrictive diseases; and b) in 12 healthy volunteers wearing high airway resistance and thoracic/abdominal bands to mimic obstructive/restrictive patients. Results: The designed ventilator provided inspiratory/expiratory pressures up to 20/10cmH2O, respectively, with no faulty triggering or cycling; both in the bench test and in volunteers. The breathing difficulty score rated (1-10 scale) by the loaded breathing subjects was significantly (p<0.005) decreased from 5.45±1.68 without support to 2.83±1.66 when using the prototype ventilator, which showed no difference with the commercial device (2.80±1.48; p=1.000). Conclusion: The low-cost, easy-to-build noninvasive ventilator performs similarly to a high-quality commercial device, with its open-source hardware description, which will allow for free replication and use in LMICs, facilitating application of this life-saving therapy to patients who otherwise could not be treated

Aplicar métodos de aprendizaje activo en educación superior

El 27 d’octubre de 2017 va tenir lloc a la Facultat d’Economia i Empresa de la Universitat de Barcelona la Primera Conferència Internacional d’Experiències en l’Aplicació de Mètodes d’Aprenentatge Actiu a l’Educació Superior. Va ser un fòrum per a la recerca d’alta qualitat en estratègies d’innovació a l’educació superior centrat en metodologies d’aprenentatge actiu, com la classe inversa, l’aprenentatge basat en equips o els experiments a l’aula.The 1st International Conference in Experiences in Active Learning in Higher Education was held on 27 October 2017 at the Faculty of Economics and Business of the University of Barcelona. It provided a forum for high-quality research in innovation in higher education focusing on active learning methodologies such as flipped classroom, team-based learning and problem-based learningLa Primera Conferencia Internacional de Experiencias en la Aplicación de Métodos de Aprendizaje Activo en Educación Superior se celebró el día 27 de octubre de 2017 en la Facultad de Economía y Empresa de la Universidad de Barcelona. Fue un fórum de investigación de alta calidad en estrategias de innovación en la educación superior centrado en metodologías de aprendizaje activo como el aula invertida, el aprendizaje basado en equipos, los experimentos en el aula, etc

Changes in the demand for private medical insurance following a shift in tax incentives

The 1998 Spanish reform of the Personal Income Tax eliminated the 15% deduction for private medical expenditures including payments on private health insurance (PHI) policies. To avoid an undesirable increase in the demand for publicly funded health care, tax incentives to buy PHI were not completely removed but basically shifted from individual to group employer-paid policies. In a unique fiscal experiment, at the same time that the tax relief for individually purchased policies was abolished, the government provided for tax allowances on policies taken out through employment. Using a bivariate probit model on data from National Health Surveys, we estimate the impact of said reform on the demand for PHI and the changes occurred within it. Our findings suggest that the total probability of buying PHI was not significantly affected. Indeed, the fall in the demand for individual policies (by 10% between 1997 and 2001) was offset by an increase in the demand for group employer-paid ones, so that the overall size of the market remained virtually unchanged. We also briefly discuss the welfare effects on the state budget, the industry and society at large